A Speech-Language Pathologist's perspective on topics of the profession

A Little About Me and This Blog

I have been a licensed Speech-Language Pathologist (SLP) since 1987. I am a member of the American Speech and Hearing Association. I have worked in the states of New York, Hawaii and Florida. I am currently in New York State. I have worked in settings that include public schools, special education preschools, hospitals, adult day treatment programs, home health rehabilitation, early intervention and preschool homebased therapy. I have provided evaluation and therapy to people ranging in age from 6 months to 100 years. I have worked with a wide range of conditions and treatments including fluency, aphasia, apraxia, voice disorders, dysphagia, cleft palate, hearing impairment, articulation delay, language delay, augmentative/alternative communication, autism, and many others through the years. The purpose of this Blog is to share information and answer questions that you may have. I will strive to provide the correct information to the best of my professional knowledge. I may not share the same professional opinion as other licensed speech pathologists and I encourage second opinions if you want to be as informed as possible.

Wednesday, February 24, 2010

Speech Development and Ear Fluid

It is common for infants and toddlers to have ear infections. It is also common for them to have an excess amount of fluid in their ears that never becomes infected. Otitis Media is the medical term for inflamation of the middle ear (the part of the ear right behind the eardrum) that is accompanied by a build-up of fluid. (The Otitis Media link above has a great deal of information and is a great supplement to this basic information I am providing). The fluid can be an infection, but this is not always the case. It is more difficult to recognize when a child has only fluid build-up because there is no accompanying pain or other symptoms. When they have an ear infection, they may cry, pull on their ears or have a fever to tip you off. You will likely take them to the doctor and they may be put on an antibiotic to clear up the infection. Once the infection is cleared up, there is still the chance that they have excess fluid. If the child has excess fluid behind the eardrum, but no pain, you may never know this situation is happening. Other children may have excess fluid in their ears for many months or constantly and it may go undetected because there is no infection.
Think of walking around with your ears plugged or being under water. The muffled sounds that you hear is how the infant or toddler with an infection or excess fluid will hear their world. This is why many children who have had recurring ear infections or chronic fluid build-up do not develop speech and language skills at a typical rate. For all of the time they have this fluid or infection, they are missing the models of speech. In an infant and toddler, a total of six months of not hearing adequately can make a big difference in development.
At times, a pediatrician will refer children to an Otolaryngologist (ENT) for tubes. These tubes have been called PE tubes meaning pressure-equalizing. They are also known as tympanostomy tubes. These tubes help keep fluid draining and work to prevent infections from recurring. One possible side effect from tubes is a small amount of scarring on the ear drum that may slightly affect hearing due to making the ear drum a bit more rigid. This is not generally significant enough to worry about, it is just a small result from a procedure that is helpful in the long run.
Children with known chronic ear infections are usually more closely followed by their pediatricians for a possible delay in speech and language development skills. This is not always the case. It is also important for parents to educate themselves in the developmental milestones their children should reach so that if there is ever a concern, they can notify the pediatrician early. The time that it may be realized that a child has non-infected chronic fluid build-up may not be until a scheduled well-baby doctor visit or at a time when the child has been brought to the doctor for an unrelated issue. Delays in sound production and language skills should be a clue that something with the child's ears may be a concern.
It is recommended that any child with recurring ear infections or delay in speech and language skills receive a complete hearing assessment. It is at this time that the reason for the delay may be discovered and addressed. A very common reason for speech delay is chronic ear infections. Once this issue is cleared up, a child will generally begin to catch up skills. Speech therapy may be recommended to help the parents and children gain missing skills more quickly. Even if a child has not had known ear infections or fluid, they should get a hearing assessment as soon as it is determined that there is any speech delay. There are other reasons for hearing loss in children and for speech delays. It is always important to have hearing tested so the correct treatment can occur.
I have been asked many times if it is possible to prevent ear infections in babies and toddlers. Although some children will get them regardless of the steps you take to prevent them (the same way they get the common cold), there are things you should know and do. A baby's eustachian tube (the tube from the ear to the throat) is smaller and positioned horizontally. Until a persons eustachian tube grows and changes angle to a more downward position, they will be more suseptible to infection and fluid build-up.
A baby should never be lying flat to drink a bottle. If they are held at an angle of at least 45 degrees, you lessen the chance of any liquid backing up and sitting in the eustachian tube, possibly causing infections. My professional opinion on this tip is also that babies should never be left propped up someplace to drink a bottle. Feeding a baby is one of the best times to bond with them emotionally and provides a perfect time to talk and interact with him. You can sing to him, look at him, encourage feedback and just bond. Speech and language skills can be learned in this time by making funny noises, showing various nice emotions in your face, saying strings of consonants-vowel combinations (ba-ba-ba or ma-ma-ma). The baby has your undivided attention and eye contact during this time. Breastfeeding is also a way to prevent ear infections for two reasons. Babies generally are not lying flat to breastfeed and they are gaining the benefits to their immune systems that breastfeeding provides. I also like the benefit of having to be with your baby while feeding, increasing the speech time!
There are several other tips for trying to prevent ear infections. Children should not be exposed to cigarrette smoke. Children who have weakened immune systems or have allergies are more susceptible, so trying to avoid having them get colds will also help. Children in large day care settings may be exposed to more colds and other germs that may increase infection risk. If a child does have a cold with nasal congestion, try to keep his nose clear of fluid to decrease back-up into eustachian tube. Provide your child with a well balanced and healthy diet rich in fruits and vegetables that boost the immune system.
feel free to ask questions here or to my direct email at beajvw@hotmail.com

36 comments:

The best time to get professional help is when your child is around 2 1/2, the age when late bloomers usually catch up. Language problems are addressed with speech therapy or by treating undiagnosed ear infections or hearing problems. Causes of speech delay in children

my son is 23 months old and I am concerned with his speech. He has had several ear infections, 2 back to back in March and the pedi said he has lots of fluid. He has many words but I feel he doesnt say them properly. Also with 2 syllable words he leaves off the second syllable (ex. cracker he says cra, Monster he says mon). He also did some nasal talking when he was younger for Sissy and cho cho. He currently still says cho cho through his nose. I have also just begun hearing him snore very loudly! Could his speech delay be from fluid? He is having a Speech eval in May and I have called the audiologist to see if we can get him in for a hearing screening.

His speech delay (if in fact it is delayed) can be related to ear infections. It is great that you are having an evaluation to determine speech and language levels. They will likely recommend a hearing evaluation as well. This is a standard recommendation for a child with the history of infectins and speech delay. With the snoring, infections and hypernasal speech, I would also think that a referral to an ENT would be a good idea as well. They will look at tonsils and adenoids as well as ears and see if there is something to be done that would improve all of the issues. Also, remember that there are typical things done by many children such as leaving off the second syllable of words, leaving off consonants or mispronouncing words due to sound substitution errors (see my post about soind development stages). Best of luck to you with the evaluation and remediation of any of his medical and speech development issues.

Hi, my son is 20 months old and isn't talking. He was making sounds like bababa, mamama, dada when he was younger. His sounds now do not use any vowels or consonents. He would mimick sounds before but now he does not. He makes lots of sounds but I can't really make them out. He thinks he is talking and can go on and on. He has conversations on the phone in his own little language. I am bringing him to an ENT next week to check hearing. He has never had an ear infection. My question is, when I was a baby, I needed tubes and had alot of problems with my ears. Is this hereditary?

I'm so sorry I didn't reply sooner. It's a great first step to visit the ENT. He will, hopefully, refer you to an audiologist for a full hearing evaluation. The ENT will check the physical ear but the audiologist will evaluate hearing ability. As far as heredity, I believe that there is not as much heredity involved as just environment and individual make-up of the childrenwith regard to ear infections. He may have never had a diagnosed ear infection, but there is a possibility that he has had fluid in his ears or even slight infections that were not notable because he may not have shown pain. The ENT should do a tympanogram to determine if there is fluid behind the eardrum. A tympanogram tests the movement of the eardrum. My recommendation to you is to follow up, regardless of what the cause of his speech delay, he needs to have it formally assessed by a speech pathologist and begin therapy to work towards bringing him up to developmental levels. At the same time, if there are any hearing related issues, they can be addressed at the same time. I'm not sure what state you are in, but here in NY, you contact the Public Health Dept in the county to move forward with referrals to local agencies for evaluations. The ENT or pediatrician are also great places to start. Best of luck to you and your family.

Hi, I have a 32-month old son who currently does not speak. He speaks "da, ba, and dee" when he is around 1 year old, but his progress has been stagnant until he was 2 years old (although occasionally he speaks "yee" and "there, there, there". he makes lots of nasal voices, especially sounds like "errr, ahrr, and eee".When he was 26months old, we bring him to a ENT to rule out hearing problem. The diagnosis is both ear blocked by earwax, and removal done, plus a simple hearing test that shows hearing is fine. After 3 months, we notice there is not much progress in speech, we go to another ENT for a throughout hearing test. the outcome is that his ears are blocked again. Earwax was removed, and hearing test was done by a audiologist shows that the hearing is perfect, after earwax had removed. No fluid buildup in mid ears.Currently we are seeing a child development specialist and scheduling for speech therapist and pshycologist. My questions is, do you have any recommended reference materials in how we can better handle, manage and improve the child's situation? Many thanks.

You are on the right track for getting things figured out. My guess is that once you have him evaluated he will be recommended for speech therapy regardless of the reason for his delay or his diagnosis. Once he begins therapy, it is important for you as a parent to be involved in his therapy. A child who gets therapy and has parent involvement with doing the same things the therapist does, will likely show more improvement. I always tell parents that I don't "fix" their child's speech in three sessions per week. They need to use strategies recommended by the speech therapist. As far as reerences, I did one post about encouraging speech and language development. That will give you techniques. Also, once in therapy, use the methods your therapist uses. Every therapy method is not for every child. She may recommend a picture communication system such as PECS (Picture Exchange COmmunication System) or a traditional language development therapy approach. Best of luck with his progress.

My 2.5 year old has been diagnosed with persistent fluid in her ears, yet she has had only 2 infections total. She shows hearing loss when tested, but it's hard to tell whether the tests are accurate because she is very quiet and shy around new people. The hearing tests included giving my daughter directions through earphones and observing whether she followed them. The ENT would like to put tubes in her ears due to a concern that her speech might delay. However, she meets/exceeds all the developmental milestones for speech. I've received mixed information regarding whether this procedure is necessary or preferred. I absolutely want to do what's best for her. Does anyone have a similar situation or insights to share?

Based on what you report, if her speech is not delayed at this time, it is not likely that it will "become" delayed. If the ENT is suggesting this, maybe he has some concerns about the level of speech development at this time. If she is speaking in phrases and using sounds that are appropriate for her age, then the hearing loss may not be affecting her development. My professional opinion would be to have a formal speech and language evaluation to determine her present speech and language levels and to really rule out whether the fluid has or will affect her development. I have known children to get tubes to help with chronic fluid. As a parent I am not in favor of surgery unless it is absolutely necessary, but as a professional, I would like all children to be sure they can hear as well as possible for the sake of all areas of development. Best of luck to you and your daughter.

My daugter turned 3 in August. She had tubes placed at 2.5 years & they just recently fell out. She also has had two ear infections total. We discovered the fluid because she had a speech delay. The tubes only really helped with her balance but I didn't notice a significant difference in her speech. Her receptive & cognitive skills are a year advanced & her expressive speech is about 9 months delayed according to developmental reports. Hearing tests are inconclusive but suggest it's just chronic fluid. We've done an ABR with showed mild hearing loss but they THINK it's just fluid. At this point we think she is just playing catch up & we are going to work with a speech therapist to help her catch up quicker but on her own she has made strides. 2 months ago she wasn't speaking in 3 word sentences & now she will have converstations with us. She still has articulation issues but we are done worrying about anything being wrong with her. She does stuff on her own time. A long time ago we were told as long as your child is making progress that's all that matters. Do your due dilligence for sure but also know when to stop chasing rabbit trails cause doctors love to look for things that could possibly be wrong.

My son who is 2 years 3 months has had hearing checked by audiologist and we've been told his hearing is perfect he currently 'babbles' and has great conversations he looks at me with such serious wee faces like he, in his mind telling me something very important - unfortunatley myself and my husband can't understand anything no real words come out !!! Today I took him and his younger brother to the docter and he told me he has fluid behind big ear drums - this is not the first time he has had this - he's never had a real ear infection just fliuid...he has asked I take him back in 4-6 weeks to see if fluid has gone and if not then to take further action!!!! The lack of speech has been a great concern to us andakes everyday life very hard at times - we're all getting frustrated as to why he's not yet starting to use basic words....I'm hoping this will be our answer to why!!! We also have a early childhood intervention lady involved now too....but as we had his hearing checked thought that it wasn't an ear issue...do these signs sound familiar ???

I hope you have begun to get the answers you need to get your son on the right track. It sounds like you were going to have a speech evaluation. It seems that they would recommend speech therapy to try to get him caught up regardless of what the reason for the delay. It sounds very familiar. Msny children who have missed out on months of optimum hearing several times during their life will likely have a delay somewhat equal to the time they missed. Best of luck of you and your son.

Thank you for your post! Very informative. My 20 month old has been slow in speaking as well. At his 18 month well check, our pediatrician referred us to the Audiologist for a hearing test & to BabyNet (a early childhood development intervention program for the state of South Carolina). So far we have:

1. 1st Hearing test - he passed some, failed some & was on the border on some. (I may be using the wrong terminology). The audiologist also noted he had negative pressure in his ears and scheduled us for a 2nd hearing test.

2. Our BabyNet screen to see if my son qualified for Speech Therapy due to his development delay. Their communication score is made up of receptive & expressive communication. My son received the highest score for receptive but was below normal for expressive. We did not qualify for BabyNet because when you balance out the scores he was in the normal range.

3. 2nd Hearing Screen - Negative Pressure was still present and we were schedule to meet with an ENT.

4. Wednesday of this week we met with an ENT who said my son had mucus like fluid present in his ears but they were not infected (My son has yet to have an ear infection in his short life - thankfully!). His diagnosis/treatment is that we are going to treat it like an infection and give him 10 days of antibiotics to see if that clears up the fluid. If not, we are going to {probably} schedule to have tubes put in.

I guess my questions for you are: 1. Does this sound like a correct treatment planto you? 2. Is this type of present fluid difficult for a pediatrician to see if it is not causing an infection? Wondering if it has been there a long time and it's not something that our pediatrician has seen at his regular well checks? 3. Is it normal that my son's delay is mainly/only speaking but that is receptive/hearing is normal? 4. Finally, (I forgot to ask this!) does fluid in the ears cause permanent hearing loss or is it more likely that once the fluid is gone that hearing will return to normal?

Again thank you for your insight. I apologize for bombarding you with all my questions! I would appreciate any additional information you might have! :)

Hi Brenda-My son is 36 months old and has had probably close to 15 double ear infections since his 1st Bday. And, just like you mentioned in your post, many of these were discovered simply by chance- at a checkup, or he refused to eat, etc., but who knows how long he had the infection before we figured it out! Before his ears got too bad, I noticed a speech delay and had him evaluated around 18 months. He qualified for speech therapy 2x/weekly and because the evaluator also saw a receptive delay, he also qualified for special instruction 2x/weekly. About 5 months into the therapy (where he made basically no progress in the expressive area, but leaps and bounds in the receptive area) his pediatrician said he needed to see an ENT after having 3 double ear infections in 1 month. Upon seeing him, the ENT immediately scheduled surgery and he had tubes implanted last January, 2012, when he was 28 months. Within a couple weeks of having the tubes put in, he finally began to make sounds, but no real words. Just the beginning sounds of words. He made very slow progress in his expressive skills from last February until August. He does now say "hi" and "bye bye" and "night night" but he is still at the speech level of about a 18 month old. His tubes fell out in August, after being in for only about 6 1/2 months, and since then he's already had 3 ear infections. He's back at the ENT and my suspicion is that he'll probably have to have tubes put back in and his adenoids removed. My question is, could his horrendous "ear history" be the sole cause of the massive speech delay he has? He's had close to 10 evaluations by psychologists, speech therapists and special educators and they all ruled out autism. I am very frustrated because I want to make sure I'm not missing something and therefore not getting him the therapy he needs, if that may be something other than speech therapy. Any opinions?

The short answer is "Yes" Ear infections can be the sole reason for a speech/language delay. Long answer...which I am better known for... The fact that he showed progress with tubes and therapy makes me think that the ear infections were a big part if not the only reason for the delay. I think getting tubes back in is probably the best way to go, since he is now back to not hearing things clearly. Some kids (especially boys) may be late speakers anyway, but if you add months of not hearing clearly to the equation, it is a double wammie. Remember...tubes allow him to start "catching up" but he still has to go through the same stages of receptive and expressive development...just at a later time. All kids have to have receptive skills before expressive can kick in...so it is totally correct that his receptive is improving sooner. You have to understand labels and concepts before you can use them expressively. I would think that tubes and continued therapy will help him catch up...at a pace as fast as is possible. If you have more questions, feel free to email me at beajvw@hotmail.com

Hi Brenda, My daughter is now almost 20 months and had tubes put in at 14 months (6 months ago) due to frequent ear infections. She is not saying much, but babbles in her own language. Both her pre and post tube hearing tests came back fine. She was evaluated last week for early intervention and did show a speech delay and will be starting speech therapy soon. Is it possible that the months of ear infections have led to her language development being behind? And is there a chance that some of it is learned behavior-- she has a brother who is 4 and is on the autism spectrum, and has a very big speech delay.... awaiting your answer here or you can email me at cheesecakjensen@hotmail.com

Hi Brenda, My son is 22 months and has speech delay. His receptive skills are on the mark. He consistently says Mama and can say apple very well, though some days it's aapuh, bappuh... i've poured over info online about apraxia versus articulation/phonological delay.. Currently his speech therapist is still calling it articulation/phono delay. We just had a 2nd hearing test and he did not pass either due to fluid in the ears and mixed responses in the sound booth... I'm not sure what I'm asking.. What is the ratio of scenarios like this being all about the fluid? He hasn't had a history of ear infections, so if he's had long-term fluid, it's been silent.. He is attempting to mimic sounds more often now but it's only in moments I can't predict. He's so smart. He can also hear the birds singing outside (he is doing well with signing also) so he can hear all kinds of things, he follows directions great.. Is it possible the fluid is causing him to not hear a certain register that would so greatly affect his ability to speak? He may be approaching 10 words but some days, duck for example seems to apply to dog and cat. I just wish I knew what to do for him. I imagine a conversation about tubes may be in our near future. How do we determine if it's the cause of this delay? Is it always an unknown, hope for the best decision? Thanks! Ashley

My girl is 3years and she is yet to pronounce words normally.Although she suffered from ear problem from 3 months old and up till now,smelling fluid still drop off her ear.Can this be the problem of her speech problem?

Hi, my son is 21 months old. He currently can say two words "bye" and "thank you". He had a doctors appointment where they did an ear test and it showed he has fluid in his ears. He has never had an ear infection or any other signs that he can't hear. We are being sent to see an ENT to see if he need tubes. We are also being send to be screen for autism. Here is my question; when we say his name he responds or we tell him to do something and he does it, not all the time but we know he does hear us. Can the fluid in his ear be what is causing the delay in his speech even though he shows signs he is listening?

Our child is in the same boat as yours. He was trying to mimic words about 6 months ago and then he kinda stopped. We've been waiting for him to start talking but there seems to be no progress to it all. They came and evaluated him from Early Intervention and noticed the delay on the speech and said we qualified for therapy.

We took him 2 times to the doctor about a month ago because of the flu and I noticed both doctors who saw him on 2 separate occasions spent a great deal of time looking at his right ear. Today, at his 2 year old appointment our regular pediatrician spent some time looking and said there was fluid in there and that it could be an ear infection. She said he could be having the issues with the sounds because of that. My son only says "sssss" instead of fish. He is able to imitate sounds, but no words other than Daddy which I had taught him many months ago and he seem to have forgotten. I think he remembered it and started saying it not too long ago.

We are getting his ears tested in the next week or so. Hopefully this will be the solution to this problem. I am really looking forward to have conversations with him. I really need us to start communicating. I think this might have been the culprit all along..

I was reading that they are able to hear certain sounds better than others, but they have issues working the minor details of the words. They might be able to comprehend your gestures or read your lips or something.. but they can't discriminate words and because of that they can not repeat them properly.. only make rough sounds. This is all very complex.. get some help on that,

Our 19 mo son has been found to have otitis media with effusion. He's had one or two infections but mostly it's been found to be clear fluid in his ears. He's doing fine with the benchmark for number of words spoken estimated at 40 or more, with many instances of two-word combinations. That said, he's been found to have mildly abnormal hearing and he has difficulty enunciating certain sounds (for example, he's said "belck" instead of "milk" for about 8-9 months). Our ENT wasn't eager to suggest tubes prior to his hearing test, and we'd like to avoid general anesthesia/surgery if possible, so I'm wondering (if the ENT is still okay with us waiting and watching), if there is any benefit to having our son work with a speech therapist at this time, knowing he has slightly impaired hearing.

I see this article is old but it came up in my search. My son who turned 2 in May is about 6 months delayed in speech. He has been in speech and is slowly developing words. We went for his hearing test yesterday and he passed the test my question is about the typanometry test results. His left eardrum didn't move and his right showed fluid. The audiologist said it might mean impaired hearing in 1 ear since the hearing test only tested overall hearing not each ear and they would probably want him back for a retest in a few weeks. But when we saw the ENT he didn't mention these results and only said not to worry my son could hear fine.

Hi,The audiologist is correct. During the time that there is excess fluid behind the eardrums there is impaired hearing as if they were hearing things under water. That fluid usually fluctuates and if he is checked again in a few weeks the results could be totally different. There are times that tubes are inserted even if the fluid isn't infection, just to let the excess drain and keep the hearing levels good for speech and language development. For the eardrum that didn't move, that is definitely the most involved no movement is not good. If you saw the ENT after seeing the audiologist, I would be concerned that he wasn't concerned... very strange for an ENT to not be concerned about tymp results of no movement! I suggest follow up with audiologist to see if fluid has decreased and maybe bring it up yourself wih audiologist and at an ENT visit and also research having tubes placed with fluid build up. Many times kids will have excess fluid in infancy and as a toddler but we never know because there may never be infections. This can definitely cause speech delay and we don't even know it is going on. Great that you are already getting speech services and that hearing levels are good, but you are right to still be concerned about the tympanometry results. Also "passing" a hearing test can just be a general level with a child that age. The sounds in the speech frequency range may not have been able to be tested at his age. Definitely follow up with audiologist and see if there is fluctuation in tymp results. Please let me know if you get this reply, since, at times, people have not gotten my replies.Brenda

Hi Brenda!very informative post. my son is 3 year 9 months and he says lot of single words and two words like sit here, lets go, can count from 1-20, sing many rhymes though not very correctly mostly the sound part but not able to form sentences yet though he understands almost everything. for his speech delay took him to ENT for hearing assessment and found out his hearing was totally fine but the ENT diagnosed fluid build up beside both here to the point that his ears has no movement. ENt prescribed augmentin for one week and told to come back for follow up after 2 months and suggested that if fluid is still there might be needing ear tubed for him. I want to know as his hearing is totally normal could undetected fluid in the ear be the reason of speech delay . also if fluid clears down, will speech therapy be required or he will catch up in the speech part in due time?your valuable response will be of immense help to me. thanks.

Undiagnosed ear fluid over time can contribute to a speech delay. The fluid doesn't need to be infected to make things sound distorted like he is under water. A child can have fluid regularly or only sometimes and it can go unnoticed often. Especially if a child does not have pain or an infection, you may never know about it and it could be making them miss sounds during the times of fluid build-up. I would recommend that you take him for a speech and language evaluation. If he gets some intervention, he will likely make more gains than if he were to just work on catching up without a little boost from therapy. A therapist will work with you to give you things to do with him throughout his day to encourage speech and language development. If he goes to any day care or preschools it can help him to be around peers with typical developing speech as models. I would get an evaluation and see what they find as his levels and what recommendations are. I do therapy with 2-4 year olds and find they do tend to make better gains with therapy and parent carryover of therapy techniques than with no therapy. Please let me know if you receive this reply. It doesn't always post to the people who ask me questions. Best of luck to you!